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Cripa Ok County Jail Investigation Findings 7-31-08

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u.s. Department of Justice
Civil Rights Division

Office of the Assistant Attorney General

Washington, D.C. 20530

By Electronic and First Class Mail

Commissioner Willa Johnson
Commissioner Brent Rinehart
Commissioner Ray Vaughn
County of Oklahoma
320 Robert S. Kerr
Suite 505
Oklahoma City, OK 73102

JUL 3 1 2008

Investigation of the Oklahoma County Jail
and Jail Annex, Oklahoma City, Oklahoma

Dear Commissioners:
We notified you of our intent to investigate conditions at
the Oklahoma County Jail and Jail Annex (~Jail") in Oklahoma
City, Oklahoma, pursuant to the Civil Rights of Institutionalized
Persons Act (~CRIPA"), 42 U.S.C. § 1997 on February 8, 2003.
Consistent with our statutory requirements, we write to report
the findings of our investigation and to recommend remedial
measures to ensure that conditions at the Jail meet federal
constitutional requirements.
See 42 U.S.C. § 1997b.
Si~ce we initiated this investigation, we have toured the
Jail on several occasions, specifically, on May 28-30, June· 9-13,
and August 27-29, 2003. Our most recent tour of the Jail was on
April 25-27, 2007. 1 This letter reports on conditions identified
on our most recent tour during which we inspected the Jail with
consultants in the fields of correctional practices and
standards, correctional health care, and environmental health
and safety. While on-site, we interviewed administrative and

For a variety of reasons~ several years elapsed between
the two tours. Despite this opportunity to improve conditions
at the Jail, however, we generally did not observe improved
conditions at the time of the second tour.


security staff, health care providers, and detainees. 2 Before,
during, and after our on-site inspections, we received and
reviewed a large number of documents, including policies and
procedures, incident reports, medical and mental health records,
and other materials.
Consistent with our commitment to provide
technical assistance and conduct a transparent investigation, we
provided extensive debriefings at the conclusion of our
inspections, during which our consultants provided their initial
impressions and concerns.
We appreciate greatly the cooperation we received from
County and Jail officials throughout our investigation. We also
wish to extend our appreciation to Sheriff John Whetsel, Major
Bobby Carson; and the staff and administration at the Jail for
their professional conduct and timely responses to our requests.
Having completed the fact-finding portion of our
investigation, we conclude that certain conditions at the Jail
violate the constitutional rights of detainees confined there.
As detailed below, we find that the Jail fails to provide for
(1) reasonable protection from harm;
(2) constitutionally-required mental health care services;
(3) adequate housing, sanitation and environmental protections;
and (4) protection from serious fire-safety risks.



The main Jail facility, operated by the Sheriff's Office,
was built in 1991 and is located in downtown Oklahoma City.
is thirteen stories tall a~d was originally designed to hold
1,250 detainees, but held 2,543 detainees at the time of our
April 2007 tour. The Jail has a daily detainee/booking of
approximately 125 deta~nees and an average annual
detainee/booking of approximately 44,000 detainees. 3 The Jail
Annex, also located in Oklahoma City, occupies the top three
floors of the Oklahoma County Courthouse. The Annex is used as

The Jail houses mainly pre-trial detainees. However,
the facility also houses some post-adjudication inmates. For the
purpose of this letter, both groups will be referred to as

Administrative offices occupy part of the first floor.
The medical ward is located on the thirteenth floor. A
recreation yard sits atop the roof of the building. The
recreation yard is the only open-air part of the Jail accessible
by detainees.

-3 -

a short-term holding facility for detainees who are awaiting
court appearances in the Courthouse. The Courthouse and Jail
Annex were built in 1936. Detainees are held at the Annex for
short periods of time, usually half a day, while awaiting their
court appearances.
The Jail contracts to house detainees from several
jurisdictions, including the Oklahoma Department of Corrections,
United states Marshals' Service, and the United States
Immigration and Customs Enforcement.


CRIPA authorizes the Attorney General to investigate and
take appropriate action to enforce the constitutional rights of
jail detainees and detainees subject to a pattern or practice of
unconstitutional conduct or conditions.
42 U.S.C. § 1997. The
rights of pre-trial detainees are protected under the Fourteenth
Amendment which ensures that these detainees ~retain at least
those constitutional rights . . . enjoyed by convicted
prisoners." Bell v. Wolfish, 441 U.S. 520, 545 (1979).
See also
Winton v. Board of Commissioners of Tulsa County, Oklahoma, 88
F.Supp. 2d 1247, 1256-8 (D.N.D. Okla. 2000) citing, Lopez v.
LeMaster, 172 F.3rd 756, 759 n. 2 (10th Cir. 1999); Garcia v.
Salt Lake County, 768 F.2d 303, 307 (10th Cir. 1985); and Barrie
v. Grand County, Utah, 119 F.3rd 862, 867 (10th Cir. 1997).
Under the Eighth Amendment, prison officials have an affirmative
duty to ensure that detainees receive adequate food, clothing,
shelter, and medical care.
Farmer v. Brennan, 511 U.S. 825, 832
(1994); Bell, 441 U.S. at 535-36, 537 n.16. Winton, 88 F.Supp.
at 1256-8. The Eighth Amendment protects prisoners not only from
present and continuing harm, but also from future harm. Helling
v. McKinney, 509 U.S. 25, 33 (1993).
This standard has been
adopted by the Tenth Circuit.
Detainees have a constitutional right to adequate medical
and mental health care, including psychological and psychiatric
services. Farmer, 511 U.S. at 832; Board of Commissioners at
1257-8. Detainees' Eighth Amendment rights are violated when
prison officials exhibit deliberate indifference to their serious
medical needs.
See Estelle v. Gamble, 429 U.S. 97, 102 (1976).
The standard for adequate medical and mental health care requires
a showing of both the subjective and objective components of
~deliberate indifference."
Deliberate indifference may be
inferred when a prison official ~knows of and disregards an
excessive risk of detainee health." Farmer, 511 U.S. at 837.


r ....

-4 -

Detainee living conditions must be ~reasonably sanitary and
safe." Farmer 511 U.S. at 832; Ramos v. Lamm, 639 F.2d 559, 567
(10th Cir. 1980); Reece v. Gragg, 650 F.Supp. 1297, 1307 (D.
Kansas, 1986). When plumbing, electrical and other physical
plant deficiencies place detainees at the 'risk of harm from
unhealthy conditions, relief may be warranted under the
Constitution. See e.g. Reece, 650 F.Supp. at 1303-1304.



Insufficient Protection from Harm

Inadequate Security and Supervision

Several factors make the Jail an unsafe environment for
detainees and staff, and have resulted in serious harm to
detainees. The Jail houses over 2,500 detainees, nearly double
its rated capacity.4 The facility, however, does not have
sufficient bed space for this size population. Throughout the
facility, we found detainees sleeping on the floor and three or
four detainees locked into two-man cells. The detainees spend
nearly 24-hours per day in these cramped quarters.
The large number of detainees, combined-with the awkward
physical layout of the Jail, makes providing adequate sight and
sound supervision of detainees in their housing units extremely
In fact, actual direct supervision of detainees at
the Jail is virtually non-existent. The facility is not
adequately staffed to maintain necessary supervision of detainees
to secure their safety.
Indeed, frequent fights or altercations
which occur in the cell areas are often the result of inadequate
housing unit supervision by Jail staff.
For example, while each housing unit or floor may house
upwards of 500 detainees, there are often only one or two
detention officers available to supervise the large number of
detainees as well as to conduct detainee sight checks.
addition, detention officers assigned to housing units must
complete daily logs, conduct safety, sanitation, and security

While overcrowding at the Jail does not create a per se
constitutional violation, the crowded conditions tax numerous
areas of Jail operations and create circumstances that contribute
to unconstitutional conditions.
For example, as will be further
explained in this letter, the excessive number of detainees in
close quarters contributes to issues such as increased violence
among detainees and the grossly unsanitary condition of cells.


inspections t and respond to detainee needs.
These detention
officers also are required to perform other duties that require
them to leave the housing unit areas t including escorting
detainees to:
the medical unitt attorney visits t visitations t
court processing; religious programs t disciplinary and
classification hearings t and t at limited times t exercise
activities. AccordinglYt detention officers have little time to
actually monitor detainees.
In addition t detainees are often left unsupervised for
extended periods of time.
For example t our review of the Jails t
Daily Staff Assignment and Inspection Reports for the month of
April 2007 revealed that numerous housing unit security posts are
not consistently staffed. Staff and detainees also reported that
sight checks for detainees are not conducted as frequently as
The administration has installed surveillance cameras within
many areas of the Jail t including the housing units t to help
address the lack of detention officers. However t blind spots
exist within the housing units t such as in the showers and the
inside of the cells t which cannot be monitored with cameras.

Compounding the lack of adequate detainee supervision within
the housing units is the limited visibility into the individual
cells. Numerous cells are so dark due to detainees covering
their cell windows and cell lights with paper towels t and other
materials t that it is difficult t if not impossible t for detention
staff to be able to provide adequate safety and security checks
of the detainees. The lack of adequate detention staff available
to adequately supervise detainees exacerbates this problem.

We observed this problem during our first round of Jail
tours in 2003.

Further t detainees have access to potentially dangerous
items. Detainees often tamper with cell doors using plastic
utensils ("sporks") that they keep after meals. These "sparks"


These examples reflect a major breakdown in security and
could potentially result in serious harm to detainees or staff.



There is an inordinately high risk of detainee-on-detainee
violence at the Jail as a result of the Jail's chronic
overcrowding, the staff's inability to supervise detainees, and
the ability of detainees to bypass at will the security of their
cell doors.
Givenrall the other security issues discussed
herein, the level of violence at the Jail is 'one of our most
significant concerns. Such violence poses a serious risk of harm
to both detainees and correctional staff)at the Jail.
Regarding detainee-on-detainee assaults, during a two-month
period shortly before our 2007 inspection, the Jail had
approximately 70 detainee-on-detainee assaults. Some of these
assaults resulted in death and/or serious injuries.

can also be used as weapons. Collecting these utensils after
meals would reduce both security and sanitation problems
("sporks" were never intended for repeat use, since they cannot
be properly washed or sanitized) .


reports we reviewed about these events documented the following:

At least two detainees were killed in these assaults.


One detainee was stabbed during a fight.


Another detainee received a fractured jaw during a


Yet another detainee had his eye lacerated during a
fight, while a different detainee was stabbed in the
eye during a fight.

We reviewed death records covering the years 2005 and
From July 2005 to October 2006, four deaths at the Jail
were the result of detainee-on-detainee assaults.
The following
is a summary of these deaths:

In March 2006, a detainee died as the result of a
dispute over commissary items. Detainees are allowed
to purchase, and keep in their cells; large amounts of
commissary items, usually foodstuff, which they
barter. 7


Also, in May 2006, a detainee essentially beat to death
his cell mate.
The assault occurred in the cell
block's dayroom area.
In a Jail report we reviewed
regarding the assault, a staff member noted ~the
alleged assailant was observed bragging about how he
beat the crap out of" the victim.
The victim had a
history of mental health issues. The alleged assailant
had a violent criminal history and had reportedly
complained about the victim's behavior before the
beating. After this incident, the assailant had yet
another altercation in his cell with another detainee.
Such factors typically warrant a careful review by
security staff to ensure there was a proper security
response. Yet it is not clear what review, if any,
ever occurred.


Another detainee died in November 2006 from injuries

As discussed in more detail in Section D, this
situation also presents sanitation and fire safety issues as the
material clutters already crowded cells. The food items attract
vermin and the packaging provides a potential source of fuel for
a fire.


sustained in an October 2006 assault. The altercation
reportedly began over a breakfast tray. According to
Jail documents we reviewed, the housing unit control
center was not staffed at the time of the incident.
The officer on duty was called to another area.

In July 2005, while in a shared cell, a detainee
assaulted another detainee in what jail documents
describe as ~a horrific and brutal" manner.
/ the assault, and after complaining to officers of a
seizure, the victim was transported to a local medical
center. He died from cardiac arrest prior to reaching
the hospital.

Prevalence of Staff Use of Force

As described above, the Jail suffers from overcrowding and
inadequate staffing. As a result, Jail staff frequently resort
to the use force to control events. Although such uses of force
are not per se inappropriate, between January 2006 and March 2007
there were 1,337 reported use of force incidents.
In the opinion
of our expert, this is an inordinately high number of use of
force incidents for a facility the size of the Jail. Of these
incidents, 504 involved some type of physical force, 105 involved
the use of pepper spray (a chemical compound that irritates the
eyes to cause pain, tears, and temporary blindness), 453 involved
the use of handcuffs, 35 involved the.use of rapid cuffs and 240
involved a planned use of force.
The majority of the emergency
uses of force incidents, which involved the use of handcuffs or
rapid cuffs, were needed as a result of detainee-on-detainee
alter,cations. Most of the planned uses of force were the result
of intervention on a detainee who was harming himself.
The fact
that a detainee was harming himself to the point where staff were
forced to intervene may also indicate a lack of needed mental
health treatment for these detainees. Mental health services
will be discussed in detail later in this letter.
Additionally, during the tour we reviewed eight video-taped
use of force incidents. These incidents involved the use of a
restraint chair or four-point restraints (the practice of binding
a detainee to a bed by the wrists and ankles).
In these
instances, intervention was initially required due to the
detainees' behaviors. However, we often noted that, by the time
the detainees were restrained in the restraint chair or
four-point restraints, the detainee was no longer resisting and
was compliant to staff orders. As a result, it is the opinion of
our expert that the restraint use was excessive and beyond the
need to control the detainee.



In summarYr we believe a number of factors combine to create
a dangerous situation at the Jail.
First r the lack of adequate
detention staff presence within the living areas provides
detainees with the opportunity to engage in illicit/behavior r
including detainee-on-detainee assaults and fights. 8 Second r
because detainees tend to be more volatile when living in
overcrowded conditions r the likelihood of fights and assaults
between detainees becomes greater. Third, there appears to be
little interaction between detention officers and detainees r
again r due largely to the lack of staff.

Inadequate Disciplinary and Classification

deficient administration of detainee

The Jail has a comprehensive policy and procedure governing
detainee discipline. While the disciplinary process generally
works well and appears to be administered in a fair manner r two
aspects of the system that are not functioning adequately are
putting detainees at risk and undermining the Jailrsability to
effectively control inmate conduct. First, the lack of
sufficient disciplinary segregation space at the Jail prevents
appropriate separation of detainees who have committed
infractions that require disciplinary segregation.
The Jail has
dedicated 25 cells on the 12th floor for this purpose. However r
these cells 'are also used for administrative segregation of
detainees. Twenty-five cells is inadequate considering the large
number of detainees who are housed at the facility and the
numerous infractions that occur routinely. According to
generally accepted standards of practice, seven to 10 percent of
the Jailrs 1 r 200 cells should be reserved for special management
purposes. Due to an insufficient number of disciplinary cells r
the Jail maintains a constant ~waiting list" of detainees who
have committed various disciplinary infractions that warrant
segregated status, but yet who remain in general population and
await sanction. The Jail tries to prioritize the more serious
offenses for disciplinary segregation. However r during our 2007
visit to the Jail r there were 16 detainees in general population
waiting to be transferred to a disciplinary cell to serve their
disciplinary sanction. At times r in order to make room for more
urgent separation needs r detention staff are forced to let a

We also note that more Jail staff would also allow
detainees greater out-of-cell timer which is currently extremely
limited r and would assist in reducing tension among detainees.


detainee out of a disciplinary cell and back to a general
population setting prior to serving his or her full disciplinary
Serious negative consequences have resulted from this lack
of disciplinary cells. Detainees are aware of the problem and
the use of disciplinary cells as a deterrent to bad behavior is
seriously compromised because the detainee may never have to
serve his or her disciplinary sanction. Further, even if a
detainee does serve the sanction, it may be very long after the
occurrence of the incident and with limited effect. This is
unacceptable correctional practice. Generally accepted
professional standards require an effective disciplinary system
and the means for separating detainees who may be particularly
dangerous or disruptive. However, the limited number of
disciplinary segregation cells thwarts the implementation of
sound correctional practice at the Jail.
In addition to the insufficient cells for use in
disciplinary segregation, the Jail staff fails to utilize the
existing cells in an appropriate manner.
Generally accepted
correctional principles require that detainees on disciplinary
segregation be housed alone in a cell. The Jail staff routinely
place two detainees who are serving disciplinary time in a single
cell. This often leads to further disciplinary issues because
many detainees serving a disciplinary sanction usually have
committed an act of violence, aggression, or other serious
Segregation is intended to punish transgressors and
protect other detainees.
Placing two detainees in a segregation
cell defeats both purposes.

ineffective classification of detainees

Further, although the Jail's classification system appears
to be operating in terms of process, it is compromised by the
overcrowded conditions at the facility.
The Jail does not have
enough available cells to match the classification level of the
detainees in a way that meets accepted standards of correctional
practice. For example, detainees are being triple-celled and in
some cases, quadrupled-celled, in order to meet the required
classification status and housing.
Notwithstanding that the Jail has adequate policies and
procedures for classifying detainees according to their risks and
needs, the overcrowded conditions at the Jail make it impossible
to cell detainees consistently according to their classification.
Thus, detainees are put at risk because the Jail cannot

-11adequately separate known potentially vulnerable detainees from
more aggressive detainees.
Similarly, the lack of sufficient staffing impacts the
Jail's ability to implement policies and procedures governing
other Jail operational matters.
These policies may be adequate
in writing, but cannot be adequately implemented.
For instance,
no matter how professional the staff, their frequent absence from
housing units means that they cannot fully implement standard
procedures on housing supervision; nor can they properly monitor
detainees for inappropriate conduct.

Deficient Suicide Prevention

Our review of the investigations involving completed
suicides and suicide attempts revealed the Jail's failure to
respond adequately to issues that CQuld help mitigate the success
of these activities. For example, in the post-incident
investigation of a March 2006 suicide attempt of a detainee, the
Jail noted the following issues:
the responding officer's radio
battery was dead; the housing unit control center was not manned;
there was not a correctional officer in the pod to provide sight
and sound observation of detainees; the location of the
responding officer was unclear; the victim's cell mate estimated
that it took at least five to 10 minutes for an officer to
respond to his calls for assistance; and there was a further
delay in getting emergency medical services to the cell area.
Ultimately, the victim survived the attempt but suffered severe
brain damage.
Many of these same issues were present when a detainee
killed himself, apparently with tampered razor blades, while in
protective custody in June 2006. The investigative report
describes the scene this way:
The area between the bunk and desk contained pooled
blood ... Blood had been dripped or smeared on every
wall of the cell. The sink was bloody and the water in
the commode was dark red with blood ... The deceased
had blood smears over a significant portion of his body

At the scene, investigators found a razor blade that had
been removed from a safety razor. The Jail's investigation and
response failed to address whether or not there were a sufficient
number of officers assigned to the unit or whether appropriate
sight checks were done on this protective custody detainee.


Other detainees have attempted suicide using razors at the
Four months earlier, in January 2006, a detainee attempted
suicide by cutting himself with a razor blade.
This individual
survived but lost a large amount of blood.
There was apparently
no floor officer available at the time of the incident. The
detainee's cell window had been covered, obscuring supervision of
the cell. Also, 30 disposable razors were found in the
detainee's cell.
Three months later, yet another detainee had to
be treated at an outside hospital for injuries he sustained by
cutting himself with a razor in a suicide attempt.
We also noted that detainees have access to other hazardous
items. We noted circumstances where detainees in the general
population had stockpiled materials in their cells, such 'as
shoestrings and laundry lines, that could be used by detainees to
hang themselves.
During our inspection, it was also clear that housing
facilities for suicidal detainees do' not include necessary safety
For instance, cells have ventilation grilles and other
fixtures that have not been modified to minimize the risk that
they may be used by an detainee to facilitate a suicide attempt.
Further, juvenile cells are particularly troubling, because they
are painted dark colors, making visibility of the inside of the
cell difficult.
The bunks are affixed in a manner that makes it
possible for a juvenile to tie a ligature to the structure in
order to commit suicide.
The foregoing factors further reinforce our general concerrts
about breakdowns in Jail security and detainee safety. They
severely undermine the Jail's efforts to conduct adequate
detainee sight checks, to control dangerous items such as razor
blades, and to ensure adequate officer coverage of detainee
living areas.

Inadequate Investigation of Serious Events

Investigative reports of serious events involving detainees
are crucial to a jail administration in identifying, and
responding to, potential systemic problems. While the Jail does
have an investigatory process, that process is often inadequate
to prevent an adequate understanding of the causes leading to an
event, or to implement measures to prevent future, similar
In some instances the investigative 'reports prepared by
the Jail's Investigations Unit lack the detail that would
identify operational problems associated.with serious events,
such as a detainee death or a use of force incident. The Jail

-13 lacks a formal process for reviewing even detainee deaths for
operational breakdowns.
Additionally, the Jail does not capture, review, or analyze
information about critical incidents in a systematic and formal
Indeed, even when investigative reports addressed
operational issues they are of minimal value because the Jail
administrator and the command staff do not have access to them.
Only the Sheriff and Under Sheriff, who are removed from the
day-to-day operations of the facility, review the reports. The
Jail administrator and the command staff should formally review
~and critique all serious incidents in order to address any noted
deficiencies that may arise from the investigations. We received
no evidence that trend information from these reviews is shared
with the Jail's operations staff.

Inadequate Health Care Services

Inadequate Access to Medical Care

Access to medical care is a fundamental right retained by
detainees in the Jails.
Farmer, 511 U.S. at 832; Board of
Commissioners at 1257-8; See also Estelle v. Gamble,
429 U.S. 97, 102 (1976). During our tour of the Jail, we
uncovered instances where detainees were not provided adequate
access to medical care, specifically acute services - with dire
While the Jail has a sick call system for detainees to
access routine medical care services, detainees' serious medical
needs are not adequately met.

The facility does not adequately screen detainees for
serious medical problems. Our review of 45 health records
indicates that the facility does not consistently provide 14-day
health assessment required by generally accepted correctional
medical standards.
Such health assessments are important for
identifying serious health needs and improves the facility's
ability to provide adequate medical and mental health care to
For instance, such screenings allow medical staff to
physically examine detainees for communicable diseases, such as
tuberculosis (~TB") ,9 and determine a detainee's medical and
mental health history.

TB is a potentially life-threatening disease commonly
found in correctional facilities.

-14 The Jail also has had some problems providing appropriate
access to medical care during emergencies.
In a particularly
disturbing incident in July 2005, a female detainee gave birth to
a three-month premature baby while in a wheelchair and handcuffed
to a handrail outside the Jail's medical area.
From reports, it
appeared the detainee was handcuffed to the rail from
approximately 11:00 a.m. to 9:00 p.m.
She reportedly asked
several times to be placed in a cell or some place where she
could lay down. The detainee had reportedly been yelling,
cursing to be put back into her cell. At about
8 p.m., the detainee was seen by mental health staff and was
cleared from special precaution status. Reportedly, the detainee
later began yelling that her water had broken.
Medical staff
examined the detainee and apparently assumed the discharge was
from a bad infection.
She was handcuffed back to the handrail.
Shortly thereafter, the detainee was found laying on the ground
·in bloody water. An officer reported observing the detainee
place her hand down her pants and pullout the baby. The baby
was pronounced dead at a local hospital.
In our expert's
opinion, this woman's care was ~unconscionable" during the hours
she was in critical need of access to medical care.
As noted earlier, when we reviewed the suicides at the Jail,
Jail reports indicated there had been critical lapses in getting
emergency medical care to detainees.
For example, as described
at page 12 of this letter, when responding to finding a detainee
hanging in his cell, the officer's radio failed to work,
resulting in a delay in accessing emergency medical services.
By the time the detainee reached a local hospital, a hospital
doctor estimated the detainee had been without oxygen for 20 to
30 minutes and suffered severe brain damage as a result.

Inadequate Mental Health Care

Jail officials violate the Constitution when they exhibit
deliberate indifference to detainees' serious mental health
States have a constitutional duty to provide necessary
medical care to their detainees, including mental health care
such as psychological or psychiatric care. Riddle v. Mondragon,
83 F.3rd 1197, 1202 (10th Cir. (N.M.) 1996); citing Ramos v.
Lamm, 639 F.2d 559, 574 (10th Cir.1980), cert. denied, 450 U.S.
1041, 101 S.Ct. 1759, 68 L.Ed. 2d 239 (1981). When prison
officials are deliberately indifferent to a detainee's serious
medical needs, they violate the detainee's right to be free from
cruel and unusual punishment. Estelle, 429 U.S. 97, at 104. ~A
medical need is serious if it is 'one that has been diagnosed by
a physician as mandating treatment or one that is so obvious that
even a lay person would easily recognize the necessity for a

-15doctor'S attention.'"

Riddle at 1202, citing Ramos, 639 F.2d at

Other than medicating detainees with Thorazine (which is an
older anti-psychotic medication with serious potential
side-effects), the Jail offers essentially no mental health
services to its seriously mentally ill. As we walked through the
Jail, we saw numerous detainees who were obviously suffering from
mental illness and in need of psychiatric care and treatment.
Yet, many of these detainees appeared to be essentially
Clearly, these detainees required more treatment
modalities than they were receiving.
It is quite likely that detainees' mental illness played a
part in two of the four deaths described earlier in this letter.
For example, in the October/November 2006 death, both the
aggressor and victim had mental health problems. The victim had
been in psychiatric restraints for agitated yelling and cursing
at unknown objects. The assailant had documented psychiatric
problems and episodes just days before the incident. A nurse's
note at the time indicates that other detainees and security
staff had voiced concerns regarding the victim who had been
stealing food, going through old eaten trays for food, and was
exhibiting manic behavior with some delusions. Jail staff stated
the detainee's behavior was nlikely to cause him to be harmed by
others." Earlier that year, the detainee told the nurse that he
had been attacking his cell mates. He also told staff he
believed his cell mates were plotting against him and
stealing his food.
Finally, he informed staff that if he
returned to his cell he would hurt himself.
Another major reason the Jail fails to provide adequate
psychiatric service is the lack of adequate mental health staff
at the Jail. There is only one full-time psychiatrist serving
the Jail. During our tour, we received conflicting information
about the number of detainees on anti-psychotic medications, but
it appeared that at least nine to 10 percent of the detainees
were taking these medications. Accordingly, the Jail should have
approximately 250 detainees taking anti-psychotic medications.
Accord~ng to the American Psychiatric Association guidelines, the
recommended staffing for psychiatrists in jails is one-full time
psychiatrist for every 75 to 100 detainees with serious mental
illness who are receiving psychotropic medication.
Thus, the
Jail has less than half the recommended number of psychiatrists
serving its detainees.
The Jail/s mortality review of the detainee who was killed
in May 2006 revealed the detainee also suffered from a

-16psychiatric illness, possibly early dementia. Appropriate mental
health therapies might have helped mitigate this situation by
ameliorating the detainee's psychosis-related behaviors that led
him to be the target of other detainees' violent assaults.
Further, and as noted previously, the use of restraints is
also problematic at the Jail because it is used in lieu of
treatment. This is especially true given the large number of
mentally ill detainees in the Jail and the fact that such
under-or-untreated detainees often engage in inappropriate
conduct as the result of psychosis-rated behavior.
Inadequate Treatment and Management of
Communicable Disease
The Jail fails to adequately treat and manage communicable
diseases. The Jail's management of TB 10 , Methicillin Resistant
Staphylococcus Aureus ("MRSA"),l1 and other infectious diseases
deviates substantially from generally accepted correctional
medical practices. A significant problem at the Jail is that the
Jail does not have adequate systems in place to ensure that these
serious public health issues are identified and monitored
For example, Jail records conflicted on the number
of MRSA cases pre.sent at the Jail. Documents identified from
zero to 22 cases 2006.
Jail staff were unable to account for the
differences in the Jail's own records.
The same unreliable data was present regarding the
identification and monitoring of detainees with TB.
Jail data
reported there were 21 cases of TB at the Jail in 2006. Of these
21 cases, Jail records showed 16 cases happened in a single month:
Such an occurrence is highly unlikely and raises
serious questions about the Jail's system for collecting,
monitoring, and recording TB data. According to our expert

The transmittal of TB can be prevented or controlled
with an appropriate TB control plan. A TB control plan provides
guidelines for identification, treatment, and prevention of
transmission of TB to staff, the public, and uninfected

MRSA are drug-resistant bacteria that can cause
life-threatening illness such as pneumonia, and skin, bone, and
bloodstream infections. MRSA is particularly prevalent and
virulent in institutions, where many people are housed in close
proximity and where basic hygiene may be lacking.


physician, "these flaws and lack of knowledge regarding the data
reported raise credibility and effectivity concerns with respect
to the Jail's entire Communicable Disease Management and Infection
Control Program."

Deficient HousinG, Sanitation and Environmental

Inadequate Detainee Housing

As noted earlier, because of the overcrowding at the Jail,
most detainees have very little living space. Detainees sleep
under tables, next to toilets, and underneath bunk beds.
Detainees are crowded into small cells with little outdoor or even
dayroom time.
Some detainees have even signed requests not to
have a cot because there is no room in their cells for a cot.
These cramped conditions breed inadequate sanitation.
In addition, the cells also are unsanitary because of
detainees hoarding commissary items. Detainees may order $150 per
week of commissary items. As noted earlier, as a result of
detainees purchasing food products, cells are filled with litter,
inviting vermin infestation, and exacerbating the risk of the
spread of infectious diseases, which are already prominent in the
Cells (asinoted above) are also rife with suicide hazards.
Conditions at the Annex are also unsanitary. Although the
detainees may only spend part of a day in the Annex, the
conditions in the facility create the risk of transmission of
infectious disease. Detainees have no soap in the cells to wash
their hands.
Further, the toilet and drinking faucets are small
units with the faucet and basin just above the uncovered, foul
smelling, filthy commode stool.
If a detainee needs water, the
detainee has to cup his hand under the faucet and lap water from
his hands close above the filth of the toilet bowl.

Inadequate Maintenance of the Jail's Physical Plant

The Jail has a new maintenance system which allows for
automated work orders to be generated, but many orders are not
being filled due to poor follow-up.
We found a number of
inoperative showers, leaking bathroom fixtures, inadequate water
temperatures, and other unsani,tary conditions that had not been
corrected for an obviously lengthy period of time.
For instance,
the water temperature is inadequate to allow detainees to clean
themselves appropriately. Shower fixtures were also broken.
Given the size of the detainee population, the loss of basic
hygiene facilities creates unnecessary health hazards.

-18Additionally, because hygiene facilities are in common areas, the
near-total lockdown status of the Jail means that detainees often
cannot shower for days at a time.
Lack of adequate preventative maintenance was also a major
issue at the Annex. Cells were dark and unclean. Cell walls were
covered with old and chipped paint to the point where the walls
could no longer be sanitized. Toilets were filthy and lacked
toilet paper.
Sinks had no hot water. Again, with detainees
crowded into cells, these such conditions create an environment
that fosters the spread of disease and infection, placing both
detainees and staff at risk.

Unsanitary Food Service Protections

The Jail serves between approximately 7,500 and 8,000 meals
daily. This includes approximately 150 "special diet" meals for
detainees requiring diets in conformance with religious beliefs or
for detainees receiving medically-required special diets for
chronic illnesses, such as diabetes or high cholesterol. 12 While
recent renovations at the kitchen have resulted in a modern
facility, we noted some deficiencies with food preparation,
storage, and handling, which creates a substantial risk of
foodborne illness. Further, only one of the food service managers
is certified. This can impact upon the adequacy of supervision of
the food service operation.
We also observed damaged kitchen equipment and inadequate
dishwashing and sanitization practices.
For example, during the
tour, we saw numerous food trays encrusted with what appeared to
be mold and food even after they had gone through the cleaning
process. These situations pose a health threat as this
potentially allows for growth and spread of bacteria.
We also noted other hazardous issues regarding the Jail food
preparations services, including: the lack of hot water for
sanitary hand washingi bird and insects getting into areas where
food was preparedi inadequate dishwashing practicesi and
ihadequate access to safe drinking water.
These factors. combine
to produce an unhealthy and unsafe environment for detainees as
well as for staff who must work in these conditions.

Inadequate Pest Control

Food service also prepares bologna sandwiches for
detainees transferred to the Annex to await court appearances.


The Jail receives pest control service monthly throughout the
facility and in the food service area, and officers and kitchen
staff are also able to file work orders for pest issues through
the maintenance work order system. When such requests are made,
the exterminator is given the list of work orders for necessary
follow up. Despite this system, we observed gnat infestation
around some showers and garbage containers; gnats can carry germs
and diseases and can pose the risk of infecting detainees and
staff. Similarly, the Jail also needs to control the amount of
food detainees collect in their cells. Large amounts of food in
areas that are not properly cleaned, such as the jail cells, can
lead to bug and insect infestations. We also observed vermin
coming out of drains; a problem that could be eliminated with
improved bathroom cleaning.
As noted above, birds fly and roost in the food service area.
We also observed that the door from the food service area to the
outside has a large gap that allows birds and insects to enter the
kitchen from the loading area.
This presents a serious danger as
birds can carry and transmit diseases.

Inadequate Laundry Services

The Jail's laundry operation is not adequate to keep pace
with the needs of the detainee population. Generally accepted
sanitation standards require routine laundering and cleaning,
using appropriate detergent and disinfectant, to prevent the
spread of disease causing bacteria, viruses, and insects such as
lice. Clothing exchange, including underwear, only occurs once a
Professional standards dictate that such an exchange take
place two to three times per week. Detainees frequently launder
their clothing in their cells' toilets or sinks, putting up
laundry lines and hanging clothes over apertures. As noted
earlier, this practice results in unsanitary conditions and
security hazards (~, suicide risks). Given the Jail's living
conditions and the risks associated with infrequent laundering of
detainee clothing, the Jail should consider more frequent clothing
exchanges to lessen public health and disease risks.

Dangerous Life and Fire Safety Deficiencies

Given the size of the Jail population and significant gaps in
supervision, fire safety is a grave concern for this Jail. We
found serious problems with fire safety training, policies, and
safety equipment. Both staff and detainees are in serious
jeopardy of injury or death during a fire emergency.


First, fire safety drills are problematic at both the main
Jail and the Annex. At the main Jail, records indicate that most
of the staff have had problems recalling appropriate fire
evacuation procedures. When we conducted a mock evacuation at the
Annex, we were told by staff that ~they have never had a fire
drill in recent memory." More disturbing, the convoluted Annex
evacuation route turned out to be barred by a locked gate, and
staff had difficulty finding the key. Should a fire or other
emergency occur, such delays could result in serious loss of life.
Second, emergency evacuation routes are not clearly posted in
the Jail. This can be catastrophic in a facility that may have
to evacuate a large detainee population with very few staff.
Third, fire safety devices are inadequate. The Jail's
self-contained breathing apparatuses are not properly secured to
prevent tampering and damage. The Annex evacuation route is the
only route out of the facility, but because of the age of the
building, sprinklers and other safety devices are not present.
The fire safety deficiencies at the Jail are serious enough
that we believe careful consideration needs to be given to taking
immediate remedial action. The Sheriff's Department also needs to
carefully consider whether the Annex can be safely used at all to
house detainees.


In order to address the constitutional deficiencies
identified above and protect the constitutional rights of
detainees, the Jail should implement, at a minimum, the following
measures in accordance with generally accepted professional
standards of correctional practice:

The Jail should ensure that there are a sufficient
number of adequately trained staff on duty to supervise
detainees and respond to serious incidents in a manner
consistent with generally accepted standards.


The Jail should implement policies and procedures to
allow adequate supervision of detainees.
This should
included conducting adequate staff rounds in all housing
areas, visually inspecting inmate cells, searching
facilities for contraband, and promptly responding to
medical and other emergencies.


The Jail should repair and maintain the Jail's physical
security features, including cell locks and doors, in


order to reduce the risk of violence and Jail

The Jail should develop and implement an objective
classification system consistent with generally accepted
correctional standards. This system should ensure that
inmates are separated based on appropriate security
factors, including disciplinary status and history of
violence. Detainees should be placed and supervised in
housing facilities that are appropriate for their
classification status.


The Jail should develop and implement incident
investigation, quality assurance and improvement
processes that identify areas requiring improvement,
prioritize reform efforts, and assist in development of
appropriate remedies.


The Jail should ensure the timely assessment,
identification and treatment of detainees' medical and
mental health care needs.
Specifically, the Jail

Provide adequate medical intake procedures;


Ensure that qualified medical staff screen
detainees properly for serious medical and mental


Provide timely and appropriate treatment for
detainees with serious medical and mental health
condi tions; .


Ensure that detainees with chronic diseases receive
screening, testing, treatment, and continuity of


Develop and implement a communicable disease plan
that allows proper identification, tracking,
treatment, and management of communicable diseases;


Provide medications, including psychotropic
medications, in a timely manner. Treatment,
including mental health treatment, needs to be
tailored to the inmate diagnoses and individual
medical needs;


Maintain complete and accurate medical records in


- - - - ---------------


an organized and readily accessible manner.
Physicians and psychiatrists need to periodically
review medical orders and monitor medication use;

Develop and implement procedures to allow timely
mental health and other specialized care for
inmates referred for such care by medical staff.
These procedures should include mechanisms to
obtain medical documents and orders from the
outside medical providers.


Provide medical and mental health staffing
sufficient to meet detainees I serious medical and
mental health needs. This includes staffing to
provide timely health assessments, mental health
evaluations, medical care, and mental health crisis
and in-patient care.


The Jail should develop and implement policies and
procedures to ensure adequate cleaning and maintenance
of facilities.
This should include mechanisms for
meaningful facility inspections, documentation, prompt
repair of damaged plumbing and other fixtures, and a
Fegular maintenance process.


The Jail should provide inmates with clean clothing and
linens and should implement adequate sanitary laundry


The Jail should ensure that food services are provided
with and proper sanitation and hygiene to minimize the
risk of food contamination and illness. .Kitchen staff
should be trained on food safety and proper food


The Jail should develop and implement pest and vermin
control procedures in accordance with generally accepted
health standards.


The Jail should provide adequate fire safety consistent
with, generally accepted standards. More specifically:

The Jail should ensure that inmate housing areas
meet generally accepted minimum standards of life
safety. To that end, all inmate housing areas,
including those at the Annex, should have adequate
fire safety features, such as functioning fire
alarms and evacuation routes, and adequate numbers


- - - -


of hygiene facilities, including properly
maintained wash basins and toilets.

The Jail should ensure that fire and life safety
equipment, including communications gear, is
functional and properly maintained.
Staff should
be trained on such equipment.


The Jail should regularly train and drill staff on
fire and emergency procedures;


The Jail should development and implement policies
and procedures to ensure adequate control of fire
and safety hazards such as chemical supplies,
razors, and materials that can contribute to
excessive fire loading.
* * * * * * * * * * * * * * * * *

Please note that this findings letter is a public document.
It will 'be posted on the Civil Rights Division's website. While
we will provide a copy of this letter to any individual or entity
upon request, as a matter of courtesy, we will not post this
letter on the Civil Rights Division's website until ten calendar
days from the date of this letter.
We hope to continue working with the County in an amicable
and cooperative fashion to resolve our outstanding concerns
regarding the Jail. Assuming there is a spirit of cooperation
from the County and the Jail, we also would be willing to send our
consultants' evaluations under separate cover.
These reports are
not public documents. Although the consultants' evaluations and
work do not necessarily reflect the official conclusions of the
Department of Justice, their observations, analysis, and
recommendations provide further elaboration of the issues
discussed in this letter and offer practical technical assistance
in addressing them.
We are obligated to advise you that, in the entirely
unexpected event that we are unable to reach a resolution
regarding our concerns, the Attorney General may initiate a
lawsuit pursuant to CRIPA to correct deficiencies of the kind
identified in this letter 49 days after appropriate officials have
been notified of them.
42 U.S.C. § 1997b(a) (1)
We would prefer, however, to resolve this matter by working
cooperatively with you and are confident that we will be able to


-24do so in this case. The lawyers assigned to this investigation
will be contacting the County's attorney to discuss this matter
in further detail.
If you have any questions regarding this
letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights
Division's Special Litigation Section, at (202) 514-0195.

/s Grace Chung Becker
Grace Chung Becker
Acting Assistant Attorney General

David Prater, Esq.
Oklahoma County District Attorney
John Whetsel
Oklahoma County
John C. Richter, Esq.
United States' Attorney
Western District of Oklahoma